Some thorny questions on home medicine reviews, medical publishing and other matters

Some time ago, an editor with long experience in the medical publishing industry and I were dreaming about creating a new type of health publication that wouldn’t take the narrow focus of so many of the existing professional publications.

It’s not surprising, of course, that magazines like Australian Doctor, Medical Observer or the latter’s new Practice Nurse tend to slant their coverage towards the perceived interests of their readers. Any sensible media organisation selects stories, writes them and displays them with the audience firmly in mind.

But one downside of silo-based publishing is that it leads to silo-based coverage of health issues, whose limitations become more apparent as we move towards an era of team-based, multidisciplinary care.

The dream of my colleague and I was that our new magazine would have a multi-disciplinary readership, and thus would cover stories in a way that didn’t give any particular weight to any particular professional perspective. That way, the stories might really be about health, rather than health professionals.

In this day and age, our magazine will probably remain a pipe dream; you don’t hear of too many new publications starting up. But I’d like to think that Croakey offers a forum for discussion across disciplines and sectors.

So I was most interested to receive a note on the “thorny issue of interprofessional practice” from Associate Professor Ann Larson, Director of the Combined Universities Centre for Rural Health, in Geraldton.

She was responding to a new study, led by researchers with a long interest in the potential of medicine reviews to reduce adverse events and improve care (including Libby Roughead from the Sansom Institute at the University of South Australia).

The study found that when GPs and pharmacists collaborated on home medication reviews for heart failure patients, the patients were less likely to end up in hospital than those who had no such review. The study was testing what happens in the real world – being based on retrospective analysis of patient records – rather than as part of a randomised controlled trial.

But for Ann Larson, the study has raised at least as many questions as providing answers.  She writes:

“Roughead’s retrospective study of the medical records of veterans with heart failure found that that a formal pharmacist intervention, in the form of home medication reviews and other consultations between the pharmacist and GP, was associated with reductions in hospitalizations.  This is consistent with other studies that have found pharmacist collaborative care to be effective.

What interests me the most is that the study also contributes to a larger debate of the value of inter-professional practice and its role in health care reform, but as such raises many questions.

How far can we generalize the experience of patients with GPs who have elected to seek pharmacist input?  In a small study I was involved in, a committed GP made at least some change in almost all patients’ (84%) medications following a home medication review (Quirke et al 2006).

However, are all GPs as receptive to pharmacists’ input?  And are patients who could benefit from a home medication review equally or more likely to see a GP who initiates collaborative care as those who do not?  If home medication reviews were mandated for certain conditions, would there be the same impact on prescribing patterns?

Another question is what causes the association between collaborative care and reduced hospitalizations?  Is it improved prescribing habits or more informed and motivated patients?  The answer will influence how these observed benefits could be extended to all Australians.

If GP’s prescribing habits are affected, then it may be that pharmacists need only conduct home medication reviews on a small of patients, but have more detailed feedback which will promote best practice prescribing.  On the other hand, if home medication reviews are effective because the pharmacist and patient communicate better than the patient does with his or her GP, then other health professionals or even trained lay people may be able to give medication education to patients with equal results.

Home medication reviews are still fairly rare in Australia.  Only 5% of this study of veterans had one.  If they were to be expanded, a number of other issues would become important.  Again, in our little study we found that while the GP was very satisfied with the program, local pharmacists felt that it was of limited financial or professional value, especially in circumstances where there is only one or two pharmacists and a requirement for constant presence at the business.

If the demand increased to the point that some pharmacists would derive most of their income from conducting HMRs, would the independent relationship between the pharmacist and GP be compromised?  Would their need to be a code of conduct to resolve situations where there was a difference of opinion or an error by either party?  Nor should we forget the patient?  What is the appropriate role for a patient and should HMRs be promoted to patients rather than to the GPs?

And finally I cannot help but speculate on the impact in rural and remote areas.  I have already mentioned the problems for the solo pharmacist.

But many small towns and remote communities lack a resident pharmacist altogether.  If HMRs are to be encouraged as an effective model of inter-professional care then it will be necessary to explore HMRs by telephone or with the assistance of another type of health worker being the eyes (and even ears) for the distant pharmacist.  If provision in the fee structure is not made for HMRs by distance, rural and remote residents will lose out again from benefiting from health care reform.

It is axiomatic that two professionals from complementary but distinct disciplines will provide better care than one professional.  The fact is that doubling the number of health professionals will be a more expensive service.  Understanding what features of collaborative care result in health gains are critical if we are to afford the better health care that we all want.”

(Quirke J, Wheatland B, Gilles M, Howden A and LARSON A. 2006. Home Medicines Review: do they change prescribing, and patient and pharmacist acceptance? Australian Family Physician. 35(4):266-267.)